Pan American Health Organization Washington, D.C. October 2, 2012

1. SOCIAL CHARTER IN THE AMERICAS ―From the Health Perspective ― Dra. Sofialeticia Morales Senior Advisor for the MDG Coordinator of Health Promotion and Social Determinants of Health Pan American Health Organization Washington, D.C. October 2, 2012

2. I. The principal challenges in Health in the Americas

3. Poverty and Inequality

4. Poverty: A Multi-Dimensional Challenge ‘Poverty is pronounced deprivation in well-being, and comprises many dimensions, including low incomes and the inability to acquire the basic goods and services necessary for survival with dignity. Poverty encompasses low levels of health and education, poor access to clean water and sanitation, inadequate physical security, lack of voice, and insufficient capacity and opportunity to better one’s life. The state of poverty vary by degree within countries and regions. Poverty is multidimensional making the solution a challenge to apply as many of the causes of poverty are inter-related.’ Source: World Bank, 2010

5. Poverty's Disproportionate Impact • Poverty and inequity are two of the greatest challenges of this century • The global GDP per year, US$74 trillion, represents an average of $30 per day per person in the world • 2.7 billion world-wide people live on less than $2 per day • Six out of ten oftheworld’spoorest people are women • Stark differences in economic opportunities explain significant health inequities between and within countries • There is a 36-year-gap in average life expectancy between Malawi and Japan • The life expectancy in Dominican Republic is 73.5 whereas in Haiti it is 62.2 –a gap of 11.3 years within the same island Median income: $143,500 Median income: $58,526 Sources: Robert Wood Johnson Foundation, 2011 Source: World Health Organization, 2011

6. II. Access to Health Services and Social Protection Programs

7. Social exclusion and inequity in the distribution of wealth, as well as access to basic services continues to be a priority for inclusive development in our region. According to the World Bank, in 2010, 1 out of 5 persons lived on less than $2 dollars a day, 15% of the US population and 11 of Canada´s population lived below the poverty line (2010 US census and 2009 Canada Census). It is worth noting the uneven progress among the countries of the region. As an example, on the island of Hispaniola life expectancy in the Dominican Republic is 73.5 years while in Haiti is 62.2 inter sectoral initiatives at the highest political level that involves the whole of government and that focus on reversing the negative effects of social determinants prove to be able to sustain the poverty reduction strategies adopted in the last 20 years. (e, g, BolsaFamilia and Oportunidades) Poverty and Access to Health Services Source: World Bank: 2008 • In 2008, Cuba had 1 physician for every 159 people, whereas Haiti had 1 physician for every 11,500 people (World Bank, 2008) • In LAC, 27% of the population is without regular access to basic health services, which equals a total of 135 million (PAHO, 2009)

8. Reducir las barreras que impiden el acceso a los servicios de salud • Barreras culturales y lingüísticas que afectan el acceso de los indígenas o afrodescendientes • Doble descriminizacion de las mujeres • Maltrato por los trabajadores salud Etnia Barreras múltiplas • Hombres: es menos probable que busquen servicios de atención • Mujeres: violencia de género, explotación/trafico sexual, • Tienen menos acceso a servicios e información Sexo/género/identidad de género • Miedo al rechazo, el estigma, y la discriminación Orientación sexual • Falta de acceso a los recursos financieros, tiempoy transporte, • Falta de información Ingreso/clase económica/social

9. El impacto de la exclusión y discriminación acumulativa Discapacidad Monolingue Indígena Edad productiva/reproductiva Género Falta poder política Analfabeta Urbano/ Rural Pobre

10. Target Universal Health Coverage of Good Quality accompanied by Social Protection Models for the most vulnerable population

11. III. Action on the social determinants and health in all policies

12. Education determines employment opportunities, family income and participation in social protection programs These factors strongly influence accessibility to health services Evidence demonstrates that families with lower levels of education have poorer health outcomes Poverty and Education 3.1 times higher Source: Macro International, 2011

13. Brazil: income growth and redistribution by deciles, 1998-2007 Hailu D, Dillon SS. IPCIG & AER; OnePager July 2009;89:2 Equity in health-the backbone for the post 2015 Development Agenda

14. Breaking the Cycle of Poverty: The Role of Social Determinants of Health • Looks at the whole picture of countries (local, national, and community) addressing the inter-related factors that impact the overall health • Encourages public policies to be evaluated and changed to improve health and well-being • Enhances the elimination of gaps in health outcomes between social groups • Allows public health professionals to look for solutions outside the health care systems to improve health • Provides a framework for countries to improve the health of people while empowering and encouraging fair opportunities across the life course • Contributes to achieving the Millennium Development Goals Age, sex & hereditary factors

15. Brazil: distributional effect on infant mortality inequality, 1997-2008 Graficasdesarrolladaspor Oscar Mujica

16. Target Regional standardized national information systems in health, and vital statistics that allow the disaggregation of data by sub national level, sex, ethnicity and race as well as economic status

17. Urban Health

18. The Continuing Challenge of Rapid Urbanization in the Americas • LAC is the most urbanized region in the developing world, with 77 percent of its population living in cities • Major cities in the United States (Atlanta, Washington D.C. & New York) have the highest levels of inequality in the country, similar to Abidjan, Nairobi & Santiago • In Belize, Guatemala and Peru over 50% of the urban population lives in slums, while in Barbados, Chile, Guyana, and Uruguay, less than 10% of the urban population lives in slums • Infant mortality ranges from 6.5% in one central area to 16% in another part of Greater Buenos Aires, Argentina (Bernardini, 2009) • In Bolivia, 93 per cent of children in small cities and towns are enrolled in primary education, compared with 68 per cent in the capital and other large cities, and 72 per cent in rural areas Urbanization in the Region of the Americas Source: UNHabitat 2009

19. IV. The social and economic burden of NCD

20. More than 200 million persons in the region suffer from and NCD 4.4 million people dying each year in the Region due to Non-communicable diseases accounting for 75% of all deaths throughout the region(PAHO Mortality database) Cardiovascular disease account for 1.9 million deaths a year; Cancer1.1 million, diabetes 260,000 Chronic respiratory diseases 240,000. Of these deaths, 37% are among persons under 70 years of age and 80% occur in middle and low income countries. The social and economic burden of NCDs Region-wide Prevalence of Obesity Source: WHO, 2008

21. A joint study between Harvard University and the World Economic Forum estimates that if measures are not taken, NCDs will cost middle and low income countries almost US$500,000million per year, equivalent to 4% of its PIB. In LAC, diabetes alone represents a cost of approximately US$65,000 million a year. Risk factors associated with NCDs such as alcohol and tobacco, lack of physical activity and poor diet reflect behaviors that can be changed by healthy life styles through community and individual commitment and this opens an opportunity and presents a challenge since 3.4 million deaths can be prevented. The social and economic burden of NCDs Source: WHO, 2008

22. educational gradient in obesity prevalence; The Americas, 2000-2010 Equity in health-the backbone for the post 2015 Development Agenda

23. Target Target: 25% reduction in premature mortality caused by the four leading NCDs (cardiovascular disease, cancer, diabetes and chronic respiratory disease)

24. V. A new perspective for violence and injury prevention in the scenario of Humans Security

25. Violence in the Americas • Violence poses a significant threat to health and wellbeing within the Americas • Drug trade-related violence appears to be increasing in some regions • Marginalized groups are especially vulnerable to violence • It is estimated that in 2005, 233000 people died as a result of violence in the Americas • 67% of these deaths were a result of interpersonal violence Dra. Sofialeticia Morales Garza Team Leader, Health Promotion and Social Determinants of Health 1. Demombynes, G. (2011). Drug Trafficking and Violence in Central America and Beyond. World Development Report Background Case Study.

26. Health Promotion and the Social Determinants of Violence Fostering of Community empowerment and participation in the development of health communities Work towards gender and economic equity and the reorientation of supportive health services Information provision, health education and life skill enhancement Health public policies to create equitable societies and healthy settings Dra. Sofialeticia Morales Garza Team Leader, Health Promotion and Social Determinants of Health

27. Violence Prevention Ecological Model Gender Regional and National Level Age Education Community and Interpersonal Level Region Ethnicity Employment Status Individual Level Violence Prevention Socio-economic Status Dra. Sofialeticia Morales Garza Team Leader, Health Promotion and Social Determinants of Health CDC, 2011

28. The Problem: Typology of Violence • Self-directed: • Suicidal behavior • Self-abuse • Interpersonal Violence • Family and intimate partner violence • Community violence • Collective Violence • Social violence • Political violence • Economic violence Dra. Sofialeticia Morales Garza Team Leader, Health Promotion and Social Determinants of Health WHO. (2002). World Report on Violence and Health.

29. Global Mortality Due to Self-inflicted Violence Dra. Sofialeticia Morales Garza Team Leader, Health Promotion and Social Determinants of Health WHO, 2002, The Injury Chart Book

30. Global Mortality Due to Interpersonal Violence • Interpersonal violence makes up a significant portion of global mortality. • However, violence related mortality disproportionally affects the region of the Americas in large numbers. Dra. Sofialeticia Morales Garza Team Leader, Health Promotion and Social Determinants of Health WHO, 2002, The Injury Chart Book

31. Self-directed Violence • Includes suicide and self-mutilation • Suicidal behavior ranges from thinking about ending one’s life to carrying out the act • Risk factors include demographics, psychiatric, biological, social and environmental factors • Interventions include treatment of mental disorders, behavioral therapy, relationship approaches, community based efforts, and societal approaches. Dra. Sofialeticia Morales Garza Team Leader, Health Promotion and Social Determinants of Health WHO. (2002). World Report on Violence and Health.

32. IPV Trends Over Time 2009 Rate: 16.96 2001 Rate: 13.1 • Violence related mortality is steadily increasing over time. • By 2020, interpersonal violence is projected to become the 14th leading cause of death worldwide (16th in 1990) and the 12th leading cause of burden of disease and DALYs lost (19th in 1990). Dra. Sofialeticia Morales Garza Team Leader, Health Promotion and Social Determinants of Health PAHO, 2009, Health Indicators Database

33. Top Twenty Countries with Highest Mortality Rate Due to Homicide in the Americas, 2006 (estimated per 1000 pop) Dra. Sofialeticia Morales Garza Team Leader, Health Promotion and Social Determinants of Health PAHO, 2010, Health Information and Analysis Project; World Bank, GINI Index, 2012

34. Interpersonal Violence Mortality Rates in the Americas By Age Group, 2000 Male IPV Mortality Rates: Americas Ages 15-29: 68.5 Globally Ages 15-29: 19.4 Americas All Ages: 34.8 Globally All Ages: 13.2 • Males ages 15 to 29 years old in the Americas have the highest interpersonal violence mortality rate of any other age group both regionally and globally. • The interpersonal violence mortality rate for males 15-29 living in the Americas is 68.5. This is over three times as high as the average interpersonal violence mortality rate worldwide for this group, 19.4. Dra. Sofialeticia Morales Garza Team Leader, Health Promotion and Social Determinants of Health WHO, 2002, The Injury Chart Book

35. Low-and middle-income countries in the Americas had mortality rates due to violence that were more than four times as high as those in high-income countries in the region in 2000. • High income countries had a lower violence based mortality rate than the worldwide average for 2000 (8.6) and low-and middle-income countries had one almost three times as high. Dra. Sofialeticia Morales Garza Team Leader, Health Promotion and Social Determinants of Health WHO, 2002, The Injury Chart Book

36. Family Violence: Abuse of the Elderly • “Elder abuse is a single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person” (Action on Elder Abuse UK).’ • Categories of elder abuse: • Physical Abuse: the infliction of pain or injury, physical coercion, or physical or drug induced constraint • Psychological or Emotional Abuse: the infliction of mental anguish • Financial or Material Abuse: the illegal or improper exploitation or use of funds or resources of the older person • Sexual Abuse: non-consensual sexual contact of any kind with the older person • Neglect: the refusal or failure to fulfill a caregiving obligation Dra. Sofialeticia Morales Garza Team Leader, Health Promotion and Social Determinants of Health

37. WHO Action Points for Violence Prevention Dra. Sofialeticia Morales Garza Team Leader, Health Promotion and Social Determinants of Health WHO, 2009, Violence Prevention: The Evidence

38. Reorientation of Health Services: Violence Prevention • Providing support and care programs • Strengthening the evidence base • Collaboration across sectors including public health and criminal justice sectors Dra. Sofialeticia Morales Garza Team Leader, Health Promotion and Social Determinants of Health

39. Target 25% reduction in mortality caused by violence.

40. IV. Relationship between health and sustainable development without exclusion

41. urban-rural inequalities in progress towards MDG7 drinking water sanitation urban rural Gráficasdesarrolladaspor Oscar Mujica

42. el mayor riesgo de muerte materna se concentra sistemáticamente en la población con menor acceso a agua potable Graficasdesarrolladaspor Oscar Mujica

43. infant mortality by quartile of access to sanitation; The Americas, 2008 Gráficasdesarrolladaspor Oscar Mujica

44. maternal mortality by quartile of access to water; The Americas, 2008 Gráficasdesarrolladaspor Oscar Mujica

45. PAHO’s Core Commitment • Vision of Health in the Americas • Values of Equity and Pan-Americanism • Focus on: • Key Countries • Special Populations • Technical Priorities Technical Priorities Key Countries Equity PAHO Vision Pan-Americanism Special Populations

46. Addressing the Causes… • In 2008, The Commision on the Social Determinants of Health launched Closing the Gap in a Generation, putting equity firmly on the global agenda • The Commission made three over-arching recommendations: • To improve daily living conditions • To tackle the inequitable distribution of power, money and resources • To measure and understand the problem and assess the impact of action

47. Institutional Initiatives

48. Health inequalities matter • Social Justice • Empowerment • Material • Psychosocial • political • Creating conditions for • people to lead flourishing • lives • Safety Motherhood • UN accountability Health of mother and Child • Faces, Voices and Places • Social Protection in Health

49. Health Promotion and Social Determinants of Health Health Equity in all Policies Good Global Governance Fair Financing Early child development and education Healthy Places Fair Employment Social Protection Universal Health Care Market Responsibility Gender Equity Political empowerment – inclusion and voice

50. Mission in Action • PAHO is strongly committed to putting equity firmly on the agenda • Equity and the Social Determinants of Health are key priorities in Health Agenda for the Americas 2008-2017 • Addressing inequities through the approach of The social determinants of health is one of the objectives in PAHO’s Strategic Plan